Local Coverage Article Billing and Coding

Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient


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General Information

Article ID
Article Title
Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient
Article Type
Billing and Coding
Original Effective Date
Revision Effective Date
Revision Ending Date
Retirement Date
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CMS National Coverage Policy

Medicare Benefit Policy Manual Chapter 6 Section 20.5.1
Social Security Act (SSA) Section 1861(s)(2)(K)(i)
42 CFR§410.27
42 CFR§482.12(c)

Article Guidance

Article Text

In response to provider requests, Noridian Healthcare Solutions, LLC (Noridian) provides the following key points related to the “incident to” regulations in the outpatient hospital setting. Note: There is no "incident to" in the inpatient setting.

Medicare may reimburse the costs of services provided either:

1. delivered personally by eligible practitioners, e.g., MD, NP, PA; or
2. delivered by hospital personnel working “incident to” the eligible practitioner’s care.

When hospital personnel provide services, the following payment requirements must be met. Services delivered incident to the services of an eligible practitioner must:

o Be an integral although incidental part of a physician’s/non-physician practitioner’s (NPP’s) professional service(s) and, hence, must always occur after an initial patient care service is provided by an eligible practitioner;

o Be delivered in accordance with a valid and signed order, i.e., written by “a practitioner who is authorized to write orders by hospital policy and in accordance with state law…” 42 CFR§482.12(c);

o Be delivered under the supervision of a physician who is an employee or has another contractual relationship with the hospital and is immediately available to provide assistance to the personnel delivering the service;

•"Immediately available" in the outpatient hospital setting means that the physician must be available in the same time-frame as the personnel designated to manage cardiac arrests (codes) in the hospital.

•The supervisor need not be in the same department as the ordering physician/NPP or in the same department in which the services are rendered but must be on the physical premises where and when the patient receives services.

The physician/NPP that provides the oversight may not bill for the services of hospital employees. Only the hospital may bill for the services of hospital employees.

All service providers must work in accordance with their skills, licensure, and/or other hospital and other Medicare requirements.


Coding Information



CPT/HCPCS Modifiers


ICD-10-CM Codes that Support Medical Necessity


ICD-10-CM Codes that DO NOT Support Medical Necessity


Additional ICD-10 Information


Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.


Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.


Other Coding Information


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2015 R1

As required by CR 10901, article is converted to a formal billing and coding type article. There is no change in coverage.

Associated Documents

Related Local Coverage Documents
Related National Coverage Documents
Statutory Requirements URLs
Rules and Regulations URLs
CMS Manual Explanations URLs
Other URLs
Public Versions
Updated On Effective Dates Status
05/07/2020 10/01/2015 - N/A Currently in Effect You are here
07/19/2016 10/01/2015 - N/A Superseded View